COPD

in
Primary Care
BY
N. OPPONG
 Introduction
 COPD is characterised by airflow
obstruction which is usually progressive,
not fully reversible and does not change
markedly over several months.
 Predominantly caused by smoking.

 Airflow obstruction is defined as FEV1

<80% predicted and FEV1/FVC <0.7.
 Significant airflow obstruction may be
present before the individual is aware of it.
 Introduction
 COPD is an important cause of
morbidity and mortality (>30,000
deaths / year in the UK).
 Estimated 3 million people in the UK
suffering from the disease (900,000
diagnosed).
 June 2006: Announcement by
Secretary of State for Health that a
new NSF will be developed to
improve standards of care and
increase choice for patients with
COPD.
 Presenting Features 1
 Over 35 years
 Smokers or ex-smokers
 Breathlessness on exertion
 Chronic cough
 Regular sputum production
 Frequent winter “bronchitis”
 Wheeze
 Exclude features of other diseases
including Asthma, Bronchiectasis, CCF and
Lung Cancer
 Presenting Features 2
On examination the following may be
present:
 Hyper inflated chest
 Use of accessory muscles of respiration
 Wheeze or quiet breath sounds
 Peripheral oedema
 Raised JVP
 Cyanosis
 Cachexia
Blue Bloaters & Pink Puffers
 Investigations
 Spirometry is crucial to demonstrate airflow
obstruction. Can be used for screening.
Also as part of initial assessment at diagnosis:
 Chest X-ray to exclude other pathology
 Full blood count to exclude anaemia or
polycythaemia
 BMI
 Other invs. that may be necessary: serial peak
flow measures, CT thorax, ECG, Echo, sputum
culture, alpha-1-antitrypsin
 Differentiating Asthma & COPD
COPD Asthma
Smoker or ex-smoker Nearly all Possibly

Symptoms under age Rare Often

35

Chronic productive Common Uncommon

cough

Breathlessness Persistent and Variable

progressive

Night time waking Uncommon Common

with DIB

Significant diurnal or Uncommon Common

daily variability
Assessment of COPD Severity
Multidimensional using:
 Severity of airflow obstruction: FEV 50-
1
80% = mild, FEV1 30-49% = moderate,
FEV1 <30% = severe
 Degree of breathlessness. Measure MRC
Dyspnoea Score.
 Exercise limitation and disability
 Assessment of productive cough
 frequency of exacerbations
 BMI
 Signs of “failing lung”: Cor Pulmonale, SaO2
≤92%
 MRC Dyspnoea Score
1 Not troubled by breathlessness except on
strenuous exercise
2 Short of breath when hurrying or walking
up a slight hill
3 Walks slower than contemporaries on level
because of breathlessness, or has to stop
for breath when walking at own pace.
4 Stops for breath after walking about 100
metres or after few minutes on the level.
5 Too breathless to leave the house or
breathless when dressing or undressing
Management
 Management 1
 COPD care should be delivered by a
multidisciplinary team including resp. nurse,
physiotherapists, dieticians, palliative care teams,
social services, occupational therapists, etc

All Patients
 Smoking cessation: NRT and oral bupropion
combined with support schemes can improve quit
rates.
 Influenza and pnuemococcal vaccination.
 Exercise advice
 Dietary advice: both over and underweight
 Mgt 2 - Symptomatic Patients
Intermittent breathlessness
 Short-acting β2-agonists such as Terbutaline and
Salbutamol. OR
 Short-acting anticholinergic agent such as Ipratropium

Persistent breathlessness
 Long-acting β2-agonists given twice daily eg. Formoterol
and Salmeterol. Main side-effects are tremors and
palpitations.
 Long-acting anticholinergic agent eg. Tiotropium can be
given once daily. Main side-effect is dry mouth.
 Oral theophyllines: reserved for patients intolerant to
inhaled therapy because of side-effects, drug interactions
and need for monitoring.
Cough
 Mucolytic agents (carbocisteine or mecysteine) for
distressing viscid sputum.
 Physiotherapy may help.
 Management 3
Patients with a disability
 Patients with a restriction in their
daily activities should be referred for
pulmonary rehabilitation.
Patients with the “failing lung”
 Refer for secondary care or palliative
care assessment
 Management 4
Patients with exacerbations of COPD
 FEV ≤ 50% and with 2 or more
1
exacerbations in a year – offer a trial of
inhaled steroid and LABA combination. Eg.
Formoterol 12mcg / budesonide 400mcg
(Symbicort) or salmeterol 50mcg /
fluticasone 500mcg (Seretide).
 With prolonged dosing consider
osteoporosis screening.
 Self management plans should be
discussed with patients including the
provision of standby antibiotics and oral
steroids.
 Referral for diagnostic help
 Diagnostic uncertainty
 Suspected severe and deteriorating COPD
 Age < 40 yrs or alpha-1-antrypsin deficiency
 Onset of cor pulmonale or presence of
significant co-morbidities
 Red flag symptoms to exclude lung cancer:
haemoptysis, clubbing
 Patients experiencing frequent infections or
exacerbations
 Requests for second opinion
 Referral for therapeutic help
 Assessment for pulmonary rehabilitation
for patients with functional disability
 Assessment for lung surgery: volume
reduction / transplantation
 Assessment for long term oxygen therapy:
FEV1 ≤ 30%, SaO2 ≤ 92%
 Assessment for ambulatory oxygen
therapy: patients who desaturate on
exercise
 Assessment for nebulised therapy
 Follow Up
 Once or twice yearly
 Smoking status and desire to quit
 Adequacy of symptom control
 Presence of complications
 Effects of drug treatment
 Inhaler technique
 Need for referral to specialist or
therapy services
 Need for pulmonary rehabilitation
 Measure FEV , FVC, MRC score, BMI
1
 Pulmonary Rehabilitation
 A multidisciplinary programme of care for
patients with chronic respiratory
impairment (MRC dyspnoea score ≥3)
 Individually tailored and designed to
optimise each patient’s physical and social
performance and autonomy
 Involves exercise, disease education,
nutritional, psychological and behavioural
intervention
 Despite its proven benefits, it is available
to only about 2% of suitable patients
 Oxygen
 Initiated by specialist service
 From Feb 1, 2006 provision of oxygen
made by the Home Oxygen Therapy
Service led from secondary care.
Criteria for assessment
 FEV <30%
1
 Cyanosis
 Polycythaemia
 Cor pulmonale
 SaO2 ≤92% when stable
 GPs can still order oxygen usually as part
of short term arrangements whilst
awaiting assessment
 Exacerbations
 A sustained worsening of the patient’s
symptoms from their usual stable state
 Beyond normal day to day variations
 Acute in onset
 Requires treatment change

Triggers
 Weather
 Viral epidemics eg. winter flu and other
infections
 Smoky environment
 High pollen levels
 Exacerbations
Cost of exacerbations:
 Mild self managed - £15
 Moderate GP managed - £95
 Severe requiring admission - £1,658
Frequent exacerbations associated with:
 Faster lung function decline, up to 25%
each year
 Worsening health status
 50% of those who survive their first
admission with COPD will be readmitted
within 6 months. 10% die during
admission and a third will die within 6
months.
 Exacerbations
Self Management
 In an exacerbation, the earlier treatment is
started the better:
 Take maximal bronchodilator therapy
 Oral steroids if symptoms persist
 Antibiotics if sputum goes yellow or green
 In flu epidemics, when alerted by public health
lab, oseltamivir should be used within 48 hrs of
onset of flu-like illness.
Indications for in-patient assessment
 Worsening hypoxaemia
 Unremitting severe breathlessness
 Confusion, drowsiness
 New onset of peripheral oedema or cyanosis
 Chest pain and fever
 End of Life Issues
Indicators for end of life criteria:
 FEV <30%
1
 Recurrent acute exacerbations of COPD (>2 per
year)
 Frequent admissions to hospital for acute COPD
 Progressive shortening of time period between
admissions
 Severe co-morbidities eg. heart failure, diabetes
etc
 Dependence on oxygen
 Severe unremitting dyspnoea at rest (MRC
dyspnoea score 5)
 Inability to carry out normal activities of daily
living, inability to self care
 End of Life Issues
For these patients consider:
 Completion of DS1500 form for DLA
 Clear management plan in consultation
with patient and carer
 Referral to specialist services: resp. nurse,
palliative care, district nurse
 Provide alert card / patient held record for
emergency services eg. OOH service.
Include preferred place of death.
 Liverpool Care Pathway: for the last 48 hrs
of life